Study: Pregnancy and Post-Covid Fatigue

This article is part of our May 2023 Immune Health special issue. Download the full issue here.

reference

Oliviera AMDSS, Carvahlo MA, Nacul L, et al. Postviral fatigue following SARS-CoV-2 infection during pregnancy: a longitudinal comparative study. Int J Environ Res Public Health.2022;19(23):15735.

Study objective

To determine the prevalence, duration and risk factors of postviral fatigue in pregnant women with SARS-CoV-2

Key to take away

The risk and duration of post-Covid fatigue during pregnancy increases with the severity of the infection.

design

Longitudinal comparative study

Participant

The researchers examined three groups of pregnant women (N=588):

• Gruppe 1 (G1): Frauen, bei denen während der Schwangerschaft eine Covid-19-Infektion diagnostiziert wurde (n=259)
• Gruppe 2 (G2): Frauen, die während der Schwangerschaft nicht auf Covid-19 getestet wurden und bei der Entbindung eine positive Covid-19-Serologie aufwiesen (n=131)
• Gruppe 3 (G3): Frauen, die während der Schwangerschaft nicht getestet wurden und bei der Entbindung eine negative Serologie aufwiesen (n=198)

Women who were vaccinated against Covid-19 were excluded from the study.

Evaluated study parameters

All women received questionnaires assessing fatigue at delivery and at 6 weeks, 3 months, and 6 months postpartum. Group 1 also received questionnaires 6 weeks, 3 months and 6 months after Covid-19 diagnosis. Investigators reviewed obstetric charts for medical history.

The questionnaire determined the presence or absence of mental or physical fatigue, pain, and loss of normal activity. For women with “significant fatigue,” researchers administered a follow-up questionnaire to better understand the symptoms. This collected further data on comorbidities or other possible causes of fatigue.

Fatigue and related symptoms were rated on a scale of 1 to 10. If a woman reported feeling tired more than 50% of the time, it was considered “mostly tired,” and if she also reported being able to do less than 50% of her normal activities, it was considered “significant fatigue.”

Women from Group 1 were further divided into three groups based on the severity of their Covid-19 symptoms: those with mild symptoms, those with moderate symptoms who required hospitalization for oxygen, and those with severe symptoms who required hospitalization and mechanical ventilation or who had multiple organ involvement. The researchers compared the severity of Covid-19 symptoms with the prevalence, severity and duration of fatigue.

Primary outcome

This study was designed to assess the prevalence, duration and risk factors for fatigue in women who develop Covid-19 during pregnancy.

Key findings

In G1, 40.6% of women followed up reported fatigue 6 weeks after diagnosis, 33.6% at 3 months, and 27.8% at 6 months. Women with severe cases of Covid-19 had a significantly higher risk (HR=2.43; 95% CI, 1.49-3.95;P<0.001) Fatigue compared to those with mild illness. G2 reported no significant fatigue compared to G3.

Cough symptoms (HR = 1.76; 95% CI: 1.07-2.96;P=0.024) and myalgia (HR=1.57; 95% CI: 1.01–2.44;P=0.060) were associated with greater fatigue over time; anosmia (HR = 0.60; 95% CI: 0.40–0.88;P=0.033) was associated with a lower incidence of fatigue. Comorbidities such as high blood pressure, heart disease and lung disease were not associated with persistent fatigue.

transparency

This study was funded by HCCOMVIDA-Chamada and the EU research and innovation program Horizon 2020 under the ZIKAlliance Grant Agreement. The funders were not involved in data collection or manuscript preparation.

Implications and limitations for practice

This study did not clarify whether pregnant women are more likely to experience post-Covid fatigue, mainly because there is no clear data on how common it is in the general public.¹

However, interesting subtleties have been raised about what can lead to post-Covid syndrome. First, it showed that the women who tested positive for Covid-19 during childbirth but had no symptoms did not experience fatigue. Additionally, greater Covid symptom severity correlated with more fatigue. It also brought to light some important questions about how we can support our pregnant patients in relation to Covid risk.

There are big differences in the data on post-Covid fatigue in the population:²This study reports a range between 15% and 87%. This makes it difficult to assess whether this pregnant population had higher or lower rates of post-Covid fatigue than other groups. A meta-analysis of 68 studies found a post-Covid fatigue rate of 32% 12 weeks after diagnosis, which is similar to the rate in the G1 cohort of this study.³This suggests that the post-Covid fatigue rate in pregnancy is similarly high compared to the general population.

However, fatigue is subjective and difficult to define. Additionally, it can be difficult to distinguish whether fatigue in women after childbirth is due to post-Covid syndrome. During the postpartum period, women recover from labor, cope with lack of sleep, nourish themselves, and attend to their infant's needs. It can be difficult to figure out what is post-Covid fatigue and what is simply due to the nature of being a newborn mother.^4.5

In addition, many other common postpartum conditions can cause fatigue, including anemia, other infections, thyroid disease, mood disorders, and cardiomyopathy. Another thing to consider is what was not taken into account in the study due to a low visit completion rate. In G1, 67.6% of the initial group followed after 6 weeks, 48.2% after 3 months and 30.5% after 6 months. The authors report that this cohort was generally of low socioeconomic status and may have had difficulty using public transportation to get to follow-up appointments during the pandemic. Therefore, we do not know which symptoms were not reported.

Women who tested positive for Covid-19 during childbirth but showed no symptoms did not suffer from fatigue.

While this study does not clearly show that pregnant women are more susceptible to post-Covid fatigue, it does correlate Covid-19 disease severity with fatigue. This is important because while it is inconclusive whether pregnancy increases susceptibility to Covid, pregnancy is correlated with higher rates of severe Covid infections and an increased incidence of adverse maternal-fetal outcomes.^6-9Against this background, it is important to consider which pregnant patients might be at higher risk of severe Covid disease. While hypertension and lung disease were not correlated with post-Covid fatigue in this study, a higher percentage of women who had these comorbidities were in G1. Although none of the subjects in G1 with fatigue were diabetics, other studies have found higher rates of post-Covid fatigue in type 2 diabetics.¹⁰

Another interesting point of this study is that positive SARS-CoV-2 serology without symptoms is not associated with post-Covid symptoms. In this study, the more severe the Covid symptoms, the greater the fatigue. Other studies have found that it is not the amount of SARS-CoV-2 virus, but rather the amount of inflammatory proteins present, that correlates with disease severity and post-Covid symptoms such as fatigue.¹¹

When pregnant patients ask about Covid in the office, it is worth considering both the increased potential for negative outcomes and any other health concerns. We can assure you that a mild case of Covid is not related to fatigue. So patients need not worry if they tested positive for Covid but had no symptoms or the symptoms were mild enough to avoid hospitalization.

With this in mind, anything we as doctors can do for our pregnant patients to reduce the likelihood of contracting Covid or the severity of their symptoms is extremely beneficial. This includes offering vaccination as an option, as this reduces the occurrence of these negative consequences.¹²